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CPG'# TO: OFFICE OF REVENUE AND RECOVERY <br /> ♦ ACCOUNT TRANSMITTAL . O py, <br /> ACCOUNT NO. DEPT. NO. REFERRAL <br /> 026000.0 <br /> LAST - GUARANTOR - FIRST Al TITLE LAST - AKA - FIRST MI TITLE <br /> RAMIREZ AUTOMOTIVE <br /> C/O NAME GUARANTOR SSN <br /> JUAN RAMIREZ <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 811 N SACRAMENTO ST LODI CA 95240 209-367-4332 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONE NO. <br /> 315 S STOCKTON ST LODI CA 95240 209-367-4385 <br /> USER REFERENCE NO. IBILL bTAT ICYCLE STATUS DATEI BMd CBMd INTI MONTHLY PAY AMT I nj _ IPYMTnATF PROB <br /> 6584 HAZMAT 1.3/20/1.0 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NO/NARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED RIEC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT. NO. DESCRIPTION AMOUNT <br /> 230 026000.0 Sm Hw Gen <5tons/yr $213.00 <br /> 2010 Hazmat Fee $285.00 <br /> State Surcharge Fee $24.00 <br /> Electronic Surcharge Fee $25.00 <br /> Hazmat Penalty Fee $28.50 <br /> Permit Fee Penalty $213.00 <br /> TOTAL $788.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> RAMIREZ AUTOMOTIVE 209-367-4332 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 811 N SACRAMENTO ST LODI CA 95240 <br /> SFQV3 } CO—OWNER <br /> AST FIRST Al TITLE SOC SEC NO, DOB DR LIC NO AUTO LIC NO <br /> I I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> RAMIREZ AUTOMOTIVE 209-367-4332 <br /> EMPLOYER STREET CITY ST ZIPCODE <br /> 811 N SACRAMENTO ST O -L2 CA 95240 <br /> REPARED BY - CHECKED BY IDATE Coy. 20 (3188) <br />